Letters to the Editor

Opinions on pharmacy benefit managers, imaging, ethics and primary care.

I have sued Medco for time spent filling out Prior Authorization forms, and won [ACP InternistWeekly, March 18, 2008]. Medco paid me $190.50 for the five specific cases argued in the lawsuit, and ignored the directive of the judge to pay for the hundred prior authorizations (about $1,500) I had billed them for since March 2006 when the case was filed.

The big three pharmacy benefit managers, CVS Caremark, Medco and Express Scripts, reported earnings of $141 billion in 2007. It takes 350,000 primary care doctors earning about $400,000 each in receipts for service to make $141 billion in a year, but we provide care to 2 billion patients in the process. What value do PBMs add to health care? And why are the U.S. Veterans Administration's prescription drug costs, using a transparent formulary based on competitive pricing, with no PBM involvement, lower than others? There is a better way to control prescription drug costs: Everyone knows it and yet no one is doing anything about it.

Like Enron did with energy, the PBMs exist simply to buy and re-sell something: drugs. They are wasteful and do not interact with the patients at the point of service. PBMs have a long record of corruption and fraud (Google “fraud, kickbacks, lawsuits” and one of the big three and see what comes up!). Even when their activity falls within the law, PBMs profit from hidden rebates and incentives that require doctors to switch prescription choices by the millions each year; activities that would violate both our oath and federal anti-kickback statutes were we, as individual physicians, to operate in like fashion. The escalating volume of PBM letters and facsimiles into our offices, demanding attention, interferes with our ability to best serve patients.

This is a critical time because the widespread adoption of e-prescribing will allow the PBMs to own both the information and the technology to access it if doctors do not take a stand now. The bold lobbying arm of the PBMs are now pushing hard on the U.S. Senate (S. 2408) and House (H.R. 4296) to pass bills to force doctors into e-prescribing, according to PBM terms.

Doctors do not have to jump through PBM hoops. We could sue them in class action lawsuits or we could refuse to work with them altogether, or both. Refusal to work with PBMs would be defensible as consistent with our oath and obligation to advocate for patients we serve. No one knows like we do how much their intrusion into our day-to-day practice is harming patient care.

Gary R. Gibson, FACP
Warren, Ohio

I've read with interest the article regarding Dr. Gibson and Medco. I think that since internists bill a gross of approximately $400-$500 an hour, the figure he asked for in compensation was low. There are staffing overhead and billing costs.

Personally, I have refused to respond to the fax requests. I only consider any changes of prescriptions if the patient requests it at an office visit after I already have the chart and reviewed it.

Prior authorizations are a major abuse of our judgment as professionals, as well as our patients, to the gain of only the insurance industry. Kudos to Dr. Gibson! Why shouldn't ACP and the American Medical Association take a major stand on this issue?

Franklyn H. Carrington, MD
Agawam, Mass.

Less imaging, more clinical skills

Drs. Groopman and Hartzband's Mindful Medicine column in the May issue about the treatment of acute appendicitis by removal of a normal kidney was most interesting about the fallibility of imaging procedures. However, little was said about clinical signs. Perhaps [pioneering abdominal surgeon Sir] Zachary Cope would have made the correct diagnosis long before such images had been heard of. Maybe we should read his “Early Diagnosis of The Acute Abdomen” again and again to temper the temptation to request imaging procedures.

D.W. Ingram, FACP
St. Johns, Newfoundland, Canada

Response to ‘Ethical Dilemmas'

I am writing in response to Dr. Farber's article. Physician should transfer records regardless of patient's bill” commentary that appeared in the May 2008 issue of ACP Internist. His perspective appears to have the support of both the American Medical Association and the American College of Physicians. It is no wonder that physicians and particularly, primary care physicians, suffer from poor morale. Their own professional organizations do not support their right be fairly compensated for their work. Perhaps it is our own egocentrism as a profession that makes us think that we must act in such a manner when no one would ever expect that an accountant would release a tax return, or a lawyer a legal brief, to a client with outstanding financial obligations. Yet, failure to release these records could have substantial impact on the emotional and financial well being of their clients.

I queried my partner about how he would respond in a similar situation. He responded that he would provide the medical records, not because it is “doing the right thing” but rather for fear of retribution, i.e. being censured by the Board of Registration or sued by the patient. I believe this response is symbolic of today's beleaguered and under appreciated physician.

Dr. Farber's perspective appears to be that of a physician protected by the ivory wall of academia who is out of touch with the front lines of private practice. As a full time employee of the University of California at San Diego, he suffers no personal financial consequences from an unpaid patient bill. He is not responsible for the salaries and benefits of his medical staff. And what physician has the time or inclination to engage in a lengthy discussion of ethics with a colleague on such a matter.

Dr. Farber may be interested to learn how frequently physicians in all specialties fail to provide medical records despite a signed release requesting such from their patients. I devote a portion of my professional effort as a physician consultant for an insurance company that provides disability coverage for large employer groups. It is my responsibility to review the medical records provided by the insured's physicians to gain a better understanding of their severity of impairment. This effort, and the insured's ability to pursue their claim, is compromised when physicians fail to provide these records as requested. It should be noted that the insurance company pays any reasonable fees to the physician providing these records and there is no reason to suspect that these patients have an outstanding balance. In this type of scenario, I believe that physician refusal to provide medical records is unethical and unprofessional, and possibly worthy of retribution, e.g. a formal complaint to their Board of Registration or licensing authority.

Getting back to the original scenario, if diagnostic test results in the patient were needed, it would be much more efficient, and just as appropriate, to query the patient as to where those tests were performed and request that the patient obtain the results (e.g. echocardiogram, stress test) from such facility. There is no need for either physician, past or present, to spend their or their office staff's time tracking down the results.

Frederic H. Schwartz, FACP
Worcester, Mass.

Primary care's primacy

Primary care's primacy problem is not new [What Would It Take to Restore the Primacy of Primary Care?”, ACP Internist, May 2008]. Primary care and primary care doctors have been struggling to survive despite repeated and continuous warnings for decades. It started as long ago as 1966 with the Millis Commission report and has been repeated by the Institute of Medicine (IOM) in 1996, and recently by the American College of Physicians (ACP), and the American Academy of Family Physicians (AAFP).

Clearly, general internists, family doctors, pediatricians, and general practitioners have lost their identities and are demoralized. How has this happened when these groups together comprise the single largest physician category in medicine?

Poor reimbursement for cognitive work compared to specialists' procedural work is the usual reason given; and although it is as true as ever and needs to be addressed, there are other reasons as well.

First, consider the lack of leadership at the primary care level. Having been active in county and state medical societies for several years, I have seen time and time again a poor representation of primary care doctors on boards and meetings in organized medicine. The few times that I have seen primary care doctors represented their participation is minimal. This lack of leadership makes it almost impossible to move any agenda forward.

Too often leadership is chosen not because of ability but because no one else wants the responsibility. The result is ineffective leadership, not passionate, committed leadership. What's more, the house of medicine is too timid to address the problems that exist within its own walls. Finding fault outside is easier, but leads nowhere. One internal problem is the plethora of specialty societies that exists, each with its own political agenda. The resulting fragmentation undermines any attempt at serious discussion of primary care's future and its needs. Specialty societies need to interact in a broader way. This should start at the level of the state medical societies. Some may see this as naive, but experience so far has shown than the old ways do not work for doctors, but against them.

Second, the American Board of Medical Specialties (ABMS), however well-intentioned it may be, has inappropriately influenced the way primary care, especially general internal medicine and family medicine are practiced. Fortunately, some physicians are expressing their concerns about this in the medical literature.

Some doctors believe that the ABMS through its certification process has gained has gained too much influence over physicians' lives. Originally, certification was voluntarily sought as a personal accolade. Now, however, it is being misused by health insurers to rank doctors in terms of their competency and probably eventually to determine their reimbursements.

A recent article in a weekly news magazine reported that if one is looking for a primary care doctor's qualifications, being certified by the ABMS is a sign that he has passed a “best practices” exam. How damaging can that be to a good but non-certified doctor?

The primary care boards have worsened the problem by adding a recertification to the original certification process that is out of sync with the reality of primary care practice. Many primary care doctors after several years in practice tend to customize their practices. They may no longer treat conditions or groups of patients that they may have treated at the out start of their careers. Some may have treated patients in the ICU, the CCU, the wards, and the nursing home but over time delegated this portion of their practices to hospitalists or others. Some that may have done minor office surgery or dealt with patients' gynecological problems or older pediatric patient over time discontinued one or more of these. Yet recertification for the primary care boards requires a knowledge base that is at variance with the reality what many primary care doctors actually do in their offices.

Clearly, the ABMS has imposed an unrealistic model of primary care.

Preparing for a recertification exam can consume several hours a week of preparation memorizing information some of which will only be regurgitated and forgotten. Some physicians take board review courses. The loss of time and money involved is considerable.

Dividing primary care recertification into two categories is one way of getting around this inconsistency: academic primary care for physicians involved in teaching residents and non-academic primary care for physicians delivering primary care in the front lines in their communities.

In addition, for recertification, the pass/fail approach needs to be eliminated. Physicians should be examined in knowledge that they use and if areas of weakness are determined, remedial education should be recommended.

Recruiting effective physician leaders in primary care, giving them an effective voice, and improving the ABMS's recertification process so it helps primary care doctors are three initiatives that have great potential to restore primary care doctors morale, their piece of mind, and their self esteem, and restore primacy to primary care.

Edward J. Volpintesta, FACP
Bethel, Conn.